A Wisconsin disability attorney recently filed a lawsuit at the District Court for the Eastern District of Wisconsin against Sedgwick Claims Management Services, Inc and the Liberty Life Assurance Company of Boston under the Employee Retirement Income Security Act of 1974, (ERISA) for arbitrarily and capriciously denying a plaintiff’s claim for long term disability benefits.
In the case of Mary Poznak V. Sedgwick Claims Management Services, Inc.; The PNC Financial Services Group, Inc. And Affiliates Long Term Disability Plan; The PNC Financial Services Group; Liberty Life Assurance Company Of Boston, the plaintiff was employed as an Asset Manager for the PNC Financial Services Group, Inc. By virtue of her employment, the plaintiff was a participant in an employee welfare benefit plan called the “PNC Financial Services Group, Inc. and Affiliates Long Term Disability Plan”. The plan was managed by Sedgwick Claims Management Services, Inc initially and later by the Liberty Life Assurance Company Of Boston (Liberty Mutual) on March 1st 2011.
Sedgwick Disability Claim History
In January 2007, the plaintiff was diagnosed with breast cancer, specifically, ductal carcinoma and three (“3”) tumors in the right breast. In addition, the plaintiff was also suffering from the symptoms of reconstructive surgeries, lymphedema, arthralgia, carpel tunnel syndrome (“CTS”), chronic pain, headaches, insomnia, sleep disturbance, and fatigue. Due to her medical conditions, the plaintiff ceased working on February 23rd 2007. The plaintiff stated that she attempted to return to work on May 15th and May 16th 2007 but became ill with a respiratory infection. She was later prescribed with an antibiotic and advised not to return to work.
Claim for Long Term Disability Benefits with Sedgwick
On May 31st 2007, the plaintiff submitted her application for long term disability benefits to the Plan. Sedgwick informed the plaintiff on June 19th 2007 that it had received the plaintiff’s application for long term disability benefits. On September 22nd 2008, the plaintiff was approved for Social security disability benefits by the Social Security Administration (SSA). The SSA acknowledged that the plaintiff had been disabled since February 27th 2007. The SSA concluded that the plaintiff’s attending physician’s assessment that the plaintiff is expressly precluded from full-time work was credible.
Following the SSA decision on September 22nd 2008 SSA decision was issued, Sedgwick did not dispute that the plaintiff was disabled from working in any full time job. Nevertheless, on June 1st 2010, Sedgwick conducted a medical review of the plaintiff’s medical records. The medical review reports that the plaintiff “has no evidence of disease at this time” and “[b]ased on the medical information provided and the conversation with Dr. Shestak, there is no evidence in the medical information, from an oncology standpoint, that would suggest the patient is unable to work.” In addition, the reports also concluded that “because [Ms. Poznak] did not have surgery in over a year [since April 29, 2009], from a plastic surgery standpoint, her surgical reconstruction is not, in any way, impacting her ability to work.”
Termination of Long Term Disability Benefits
Sedgwick determined on June 10th 2010 in its Internal Claim Notes that “Ms. Poznak has been found to be capable of working in a sedentary capacity with avoidance of repetitive movement of right arm and hand.” On June 23rd 2010 not long after the plaintiff underwent surgical procedure; Sedgwick terminated the plaintiff’s long term disability benefits and stated that the plaintiff was not eligible for continued benefits beyond May 31st 2010.
Multiple Appeal Denials By Sedgwick
According to the lawsuit, Sedgwick was aware that the plaintiff had an upcoming surgical procedure on June 15th 2010 and would require 4 weeks of healing period. Knowing this, the plaintiff alleged it was arbitrary and capricious for Sedgwick to terminate her benefits during the healing period. In addition, the plaintiff alleged that Sedgwick had relied extensively on the inconsistent and erroneous reviews by its Independent Physician Consultants in its determination to deny the plaintiff’s claim for long term disability benefits. Subsequently, on December 9th 2010, the plaintiff filed an appeal to Sedgwick’s decision on June 23rd 2010 to deny of her long term disability benefits.
Another review was performed by Sedgwick on December 20th 2010 by a board certified doctor in occupational and environmental medicine on the plaintiff’s medical records. The medical review report incorrectly concluded that “no additional surgery was indicated” even though the plaintiff’s medical record indicated that the plaintiff still requires additional surgeries including surgery for reconstruction of her right nipple and a reduction of her left breast for symmetry.
Based on the erroneous medical review report, on February 4th 2011, Sedgwick informed the plaintiff that it was upholding its prior decision to deny the plaintiff her long term disability benefits. Sedgwick based its denial of benefits on the ground that the plaintiff’s disability plan is total and continuous and “as no benefits were approvable for the period of June 1, 2010 through June 14, 2010, no benefits are payable as of June 15, 2010.”
The Claim For Relief
The plaintiff stated that Sedgwick’s denial of disability benefits for the period of May 31st 2010 to June 14th 2010 was advantageous for Sedgwick because it allowed it to deny the plaintiff’s ongoing benefits for the period of June 15, 2010 to July 15, 2010 and thereafter, based on the total and continuous nature of her disability plan.
In the lawsuit, the plaintiff maintained that her condition did not improve such that she was able to return to any full-time work between May 31, 2010 and June 14, 2010, it was arbitrary and capricious for Sedgwick to deny her benefits during that period. To this day, the plaintiff still takes prescription medication, Arimidex, daily for the treatment of her breast cancer. Hence, the plaintiff is seeking from the Court the following relief:
- Judgment against Sedgwick/Liberty Life awarding the plaintiff damages for losses of benefits pursuant to the Plan and ERISA.
- Judgment against Sedgwick/Liberty awarding the plaintiff her costs, disbursements,
- Prejudgment interest, actual attorney’s fees and expert witness fees.
- Such other relief as the Court deems just and equitable.